WQ0002882_Application_20220830

DWR
State of North Carolina
Department of Environmental Quality
Division of Water Resources
Division of Water Resources 15A NCAC 02T.06,00 — SINGLE-FAMILY RESIDENCE
WASTEWATER IRRIGATION SYSTEM — RENEWAL
FORM: SFRWWtS-R 02-21
Pursuant to 15A NcAc orr .0107(b), if the application does, not include all required information and the necessary supporting
documentation, the application shall be returned. The application and attachments shall be prepared in accordance with .15A
NCAC 02T .0100, 15A 1"1CACO21.0600, and Division Policie& For more information, visit the Water Quality Permitting
Section's Non -Discharge Branch website. The Applicant shall submit an electronic copy of the application and attachments
uploaded as a single Pot -table Document Format (PDF) file to ttal-
Form-Ver2I oremailed to Non-_Dischat—gc.Rep.ores jLaLncdenr.go%, if less than 20 megabytes (MB).
SECTION II — FACILITY IN FORMATION
L Physical address: 140 South Lakeshore Drive
City: Whispering Pines
S E CT I ONJIT 8
Billing address: 140 South Lakeshore Drive
City: Whispering Pines
2. Verify the Applicant does not have any overdue annual fees:
Pursuant tol. 5A'NC/
an unpaid annual fee.
County: Moore
State: NC Zip; 28327-
State: NC Zip: 28327-
pen-nits for renewing facilities shall not be granted if the Applicant or any affiliation has
FORM� SF'RWWIS-R 02-21 Page I of 4

SECTIONIV — OVERATIONAl' D MAINTENANCE AGREEMENT
Permit No.: WQ002882 County. Moore
Permittee: Colin and Einiliana Webster (i.e., all deeded properly owners)
The Permittee agrees to operate and maintain the single-family residence wastewater treatment and irrigation system as
to] lows:
I , Inspect the septic tank annually, and pump out solids as needed.
2. Inspect and clean the septic tank effluentfilter annnally. (ifapplicable)
3. Inspect the: tablet chlorinator weekly. Add wastewater grade chlorine tablets (e.g., calcium hypochlorite) as needed.
Swimming pool grade chlorine tablets are not acceptable. (ifapplicable)
4, Inspect the ultraviolet disinfection unit weekly. Clean or replace the lairips and quartz sleeves as needed. (if
qpplicable)
5. Inspect all storage tanks, purrips, and alarms monthly, Remove the floating scum layer in all pump/storage tanks
when pumping the septic tank solids out,
6- Inspect the spray irrigation system monthly to verify: proper operation of the spray heads; that, there are no leaks;
that vegetative growth does not obstruct the .spray heads, i that the irrigated wastewater is not ponding in or running
off the designated irrigation area; and that there are no objectionable odors, (tfopplicable)
7. Inspect the drip irrigation system monthly to verify: proper operation of the drip lines; that there are no leaks; that
vegetative growth does not obstruct the. drip emitters-, that the irrigated wastewater is not ponding in or running off
the designated irrigation area; and that there are no objectionable odors, (rf apl)licable)
8. Maintain as set of Di vi sion -approved engineering plans and specifications,
Pay the required annual fee.
10. Request renewal of this permit on Division-approvedforins no later than 180 days prior to expiration.
11. Sign and provide a Qiarigc,, f Qwnei:sicatioL e wastewater_ llk� qppl- _)' to any future owner of the single-family residence~
treatment and irrigation system for their completion and submission to the Division of Water Resources.
UWe understand the above requirements and agree to these terms as part of the issued pennil,
Signature: Date: o
Signature: Date: <5 >C -?
Signature: Date:
Signature: Date:
All deeded Provertv owners shall sign this Operation and Maintenance Agreemetit
FORM: SFRWWIS-R 02-21 Page 2 of 4

Was the facility originally permitted or had a trukjor modification issued after September 1, 2006?
Yes — Pursuant to 15A NCAC 021".0105(d), submit a site map pursuant to the requirements in 15 A NCAC 02'F.0604(d), 17hese
requirements are:
A scaled map of the site with topographic contour intervals not exceeding 10 feet or 25 percent of total site relief and showing
all facility -related structures and fences within the wastewater treatment, storage, and irrigation areas.
Fl Soil mapping units shown on all irrigation sites.
0 I'lie location of all wells (including usage and construction details if available), streams (ephemeral, intermittent, and
perennial), springs, lakes, ponds, and other surface drainage features within 500 feet of all wastewater treatment, storage,
and irrigation, sites.
L] Delineation of the compliance and review boundaries per 15A NCAQ 02L.0 107 and .0 108 and 15A NC. AQ 02Tw. 60 1.
L1 Setbacks as required by j 5A NCAC 02T -06Q&
Cl Site property boundaries within 500 feet of all wastewater treatment, storage, and irrigation sites.
171 All habitableresiderices or places of public assembly within 500 feet of all treatment, storage, and irrigation sites.
No -- Skip Attachment A.
ATTACHMENT 8 — SIGNATURE A-UTHORITY'DELEGATION
Does the signature authority in Section 1, Item 3 meet the requirements pursuant to 15A NCAC 02T .0 1 06(b)?
Z Yes Skip Attachment B.
E] No — Submit a dele-do lettcaw pursuant to 15A N(,,A C (121O 10 authorizing the signature authority to sign.
Does the existing permit include an approved flow reduction?
Yes — Submit a copy of the flow reduction approval letter, as wet I as the measured monthly average amount of wastewater:flow
contributed per unit for the 12 months, prior to permit renewal. if any of these monthly averages are within 20% of the approved
flow reduction value, the Permittee shall provide a reevaluation of the reduced flow value pursuant to the requirements in 1-5-A
NQAC 02T.I
_—L_ 1
Z No — Skip Attachment C.
i ATTACHMENT D — EASEMENT, ENCROACHMENT, AND LEASE AGREEMENTS
Does the Pennitice own all of the land associated with the wastewater collection, treatment, conveyance, and irrigation system?
Z Yes --- Skip Attachment 1).
No — Pursuant to 15; _NC AQ,92T TLIA(c), provide a copy of all easements, lease agreements, and encroachment agreements
allowing the Permittee to operate and maintain the wastewater collection, treatment, conveyance, and irrigation system Oil
property not owned by the Permittee.
ATTACHMENT E — AFf
Are the Permittee's affiliations ofrecord correct'? Check affiliations.
Z, Yes — Skip Attachment E.
0 No —Provide the corrected affiliations and their contact information.
ATTACHMENT F — COMPLIANCE SCHE DULES
Does the existing permit include any Compliance Schedules'? (See Section I of the most recently issued permit.)
[] Yes — Submit documentation that the compliance schedules have been rnet.
Z No Skip Attachment F.
FORM: SFRWWIS-R 02-21 Page 3 of 4

Does the Perinittee have any existing civil penalties or outstanding violations'?
0 Yes (civil penalties) - Submit payment for the civil penalty, or proof of remission request.
El Yes (violations) Submit a copy of your response to the Notice of Violation.
Z No - Skip Attaclyrrient G.
Does the existing permit include setback waivers?
El Yes -- Pursuant to 15A N..C,AC 02T'._,06Qi6..(c), provide setbacks waivers that have been written, notarized, signed by all parties
involved, and recorded with the county Register of Deeds. Waivers involving the compliance boundary shall be in accordance
with l 5A NCAC 021, .O JOT
0 No - Skip Attachment 14,
L' k hj, W f F-� ,-�Fe- attest that this application
(Signature authority's name as noted in Section 1, Item 3)
has been reviewed by race and is accurate and complete to the best of my knowledge. I understand that if all required parts of this
application package are not completed, and that if all required supporting information and attachments are not included, this
application package will be returned as incomplete. I further certify pursuant to 15A NCAC 02T �Qj2Q Ub, that the applicant, or any
parent, subsidiary, or other affiliate ofthe applicant has; not been convicted of environmental crimes under; not previously abandoned
a wastewater treatment facility without properly closing the facility; not paid a civil penalty; not been compiiant with any compliance
schedule in a pen -nit, settlement agreement, or order; not paid an annual fee.
Note. The Applicant's Certification shall be signed pursuant to.1.5A NCAC'k b . An alternate person may be delegated as
Z' .E_�LQkU
the signing officia➢ if a letter is provided pursuant to 15A NCAC Q?"F .0 06 c). Pursuant to § 11, 43-215,6A and § 143-2 15 .0,U, any
person who knowingly makes any false statement, representation, or certification in any application package shall, be guilty of a Class
2 misdemeanor, wl�tch may include a fine not to exceed S10,000 as well as civil penalties up to $25,000 per violation.
Signature: Date: —Q�s - 5 —0- z el z
THE COMPLETED APPLICATION AND ATTACHMENTS SHALL BF SUBMITTED AS A SINGLE PDF FILE "VIA;.
Email:
Non-D,iseElLivar,L,e.iiilei)or-ts(ii),n,cdeTiEaov
g_
Laser -riche Upload-
SubmiLtail-FoLm-Ver2
FORM- SFRWWIS-R 02-21 Page 4 of 4